Invasive pituitary adenoma

Invasive pituitary adenoma

Invasive pituitary adenomas are benign pituitary tumors that infiltrate the dura matercranial bone, or sphenoid sinus. Gross invasion at the time of operation is observed in up to 35 % of pituitary adenoma1) 2) 3).

Clinically nonfunctioning pituitary adenoma (NFPA) is a very common type of intracranial tumor, which can be locally invasive and can have a high recurrence rate.

Atypical or aggressive pituitary adenomas are tumors that rapidly increase in size and may invade into the suprasellar or parasellar regions. They are characterized by a Ki-67 nuclear labeling index greater than 10 %.

Invasive pituitary adenoma molecular markers.

They can be presented as Non-pulsatile exophthalmos.

Infrequently they produce cerebrospinal fluid rhinorrhea.

Invasive pituitary adenomas and pituitary carcinomas are clinically indistinguishable from pituitary adenoma until identification of metastases.

Invasive pituitary adenoma treatment.

Aggressive pituitary adenomas (APAs) are pituitary tumors that are refractory to standard treatments and carry a poor prognosis.

A 57-year-old man presented with visual deterioration and bitemporal hemianopsiaMRI of the brain demonstrated a sellamass suspected to be pituitary macroadenoma with a displacement of the stalk and optic nerve impingement. The patient underwent stereotactic endoscopic transsphenoidal resection of the mass. Postoperative MRI demonstrated gross total resectionPathology revealed a sparsely granulated corticotroph adenoma with malignant transformationImmunohistochemistry showed a loss of expression of MLH1 and PMS2 in the tumor cells. Proton therapy was recommended given an elevated Ki67 index and p53 positivity. Before radiotherapy, there was no radiographic evidence of residual tumor. Temozolomide therapy was initiated after surveillance MRI showed recurrence at 16 months postoperatively. However, MRI demonstrated marked progression after 3 cycles. Next-generation sequencing using the MSK-IMPACT platform identified somatic mutations in MLH1 Y548lfs*9 and TP53 R337C. Immunotherapy with ipilimumab/nivolumab was initiated, and MRI demonstrated no residual tumor burden 34 months postoperatively.

APA is a tumor with frequent recurrence and a short median expected length of survival. Shah et al. demonstrated the utility of immunotherapy in a single case report of APA, with complete resolution of recurrent APA and improved survival compared with a life expectancy 4).


1)

Oruçkaptan HH, Senmevsim O, Ozcan OE, Ozgen T. Pituitary adenomas: results of 684 surgically treated patients and review of the literature. Surg Neurol. 2000;53:211–219.
2)

Scheithauer BW, Kovacs KT, Laws ER, Jr, Randall RV. Pathology of invasive pituitary tumors with special reference to functional classification. J Neurosurg. 1986;65:733–744.
3)

Selman WR, Laws ER, Scheithauer BW, et al. The occurrence of dural invasion in pituitary adenomas. J Neurosurg. 1986;64:402–407.
4)

Shah S, Manzoor S, Rothman Y, Hagen M, Pater L, Golnik K, Mahammedi A, Lin AL, Bhabhra R, Forbes JA, Sengupta S. Complete Response of a Patient With a Mismatch Repair Deficient Aggressive Pituitary Adenoma to Immune Checkpoint Inhibitor Therapy: A Case Report. Neurosurgery. 2022 May 13. doi: 10.1227/neu.0000000000002024. Epub ahead of print. PMID: 35544035.

Intracerebral hemorrhage minimally invasive surgery

Intracerebral hemorrhage minimally invasive surgery

Surgical treatment for hematoma evacuation has not yet shown a clear benefit over medical management despite promising preclinical studies. Minimally invasive treatment options for hematoma evacuation are under investigation but remain in early-stage clinical trials. Robotics has the potential to improve treatment 1)


Cavallo et al systematically reviewed the role of MIS in the acute management of ICH using various techniques.

A comprehensive electronic search for relevant articles was conducted on several relevant international databases, including PUBMED (Medline), EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL).

The primary literature research resulted in 1134 articles. In total, 116 publications finally met the eligibility criteria to be included in this systematic review. Five major MIS categories for the evacuation of ICH were identified, respectively: minimally invasive direct aspiration with or without thrombolytics, endoscope assisted technique, sonothrombolysis, aspiration-irrigation device and endoport-assisted evacuation.

The role of minimally invasive techniques in the management of ICH remains under dispute. However, a mounting evidence in the literature demonstrates that MIS is associated with significantly improved outcomes when compared with conservative treatment and conventional surgical evacuation strategy 2).


In December of 2016, phase 2 of the Minimally Invasive Surgery Plus Rt-PA for ICH Evacuation (MISTIE) study demonstrated that this form of stereotactic thrombolysis safely reduces clot burden and may improve functional outcome 6 months after injury. A smaller arm of this study, the Intraoperative Stereotactic Computer Tomography-Guided Endoscopic Surgery (ICES) study, also demonstrated feasibility and good functional outcome for endoscopic minimally invasive evacuation. Early-phase clinical studies evaluating various forms of minimally invasive surgery for intracerebral hemorrhage evacuation have shown safety and feasibility with a preliminary signal towards improved functional long-term outcome. Results from phase 3 studies addressing various minimally invasive techniques are imminent and will shape how intracerebral hemorrhage is treated 3).


Meta-analyses of surgery for ICH have also indicated that minimal interventional techniques using topical thrombolysis or endoscopy via burrholes or even twist drill aspiration may be particularly successful for the treatment of supratentorial ICH, especially when the clot is deep seated. Ongoing CLEAR III Clinical Trial and MISTIE III Clinical Trial should confirm this in the fullness of time 4).

Some minimally invasive treatments have been applied to hematoma evacuation and could improve prognosis to some extent. Up to now, studies on minimally invasive surgery for patients with spontaneous intracerebral hemorrhage are still insufficient.

The MISTICH is a multi-center, prospective, randomized, assessor-blinded, parallel group, controlled clinical trial. 2448 eligible patients will be assigned to neuroendoscopy group, stereotactic aspiration group and craniotomy group randomly. Patients will receive the corresponding surgery based on the result of randomization. Surgeries will be performed by well-trained surgeons and standard medical treatment will be given to all patients. Patients will be followed up at 7 days, 30 days, and 6 months. The primary outcome of this study is unfavorable outcome at 6 months. Secondary outcomes include: mortality at 30 days and 6 months after surgery; neurological functional status of 6 months after surgery; complications including rebleeding, ischemic stroke and intracranial infection; days of hospitalization.

The MISTICH trial is a randomized controlled trial designed to determine whether minimally invasive surgeries could improve the prognosis for patients with spontaneous intracerebral hemorrhage compared with craniotomy 5).

Endoscopic surgery for intracerebral hemorrhage

see Endoscopic surgery for intracerebral hemorrhage.


The MIS score is a simple grading scale that can be utilized to select patients who are suited for minimal invasive drainage surgery. When MIS score is 0-1, minimal invasive surgery is strongly recommended for patients with spontaneous cerebral hemorrhage. The scale merits further prospective studies to fully determine its efficacy 6).

Minimally invasive technologies, such as endoport systems, may offer a better risk to benefit profile for ICH evacuation than conventional approaches.

see BrainPath endoport system


Endoscopic surgery is increasingly used to evacuate ICHs; however, the narrow rigid sheath may be limiting. Hwang et al report the usefulness of a soft plastic membrane sheath for endoscopic evacuation of ICHs.

The 20 × 100-mm flat membrane sheath was made of polyester film. Before introducing the sheath into the ICH cavity under navigation, one side was tucked into the opposite side to make a narrow four-layered tube. After inserting it in the brain, the tucked-in leaf was pulled out, and the slit-like tube was ready to remove the hematoma. A rigid endoscope and various instruments were introduced into the sheath. Large ICHs in the putamen and thalamus were evacuated under endoscopic visualization using the same microsurgical instruments.

This technique was applied to 41 patients. Nearly complete evacuation of all hematomas was achieved. No surgical complication or rebleeding occurred. The new membrane sheath allowed more room for accommodating and handling the instruments, including bipolar forceps.

This flat membrane sheath is disposable and easy to prepare, which could overcome the limitation of the instruments to allow for efficient evacuation of an ICH using the same microsurgical techniques 7).


1)

Musa MJ, Carpenter AB, Kellner C, Sigounas D, Godage I, Sengupta S, Oluigbo C, Cleary K, Chen Y. Minimally Invasive Intracerebral Hemorrhage Evacuation: A review. Ann Biomed Eng. 2022 Feb 28. doi: 10.1007/s10439-022-02934-z. Epub ahead of print. PMID: 35226279.
2)

Cavallo C, Zhao X, Abou Al-Shaar H, Weiss M, Gandhi S, Belykh E, Tayebi-Meybodi A, Labib M, Preul MC, Nakaji P. Minimally invasive approaches for the evacuation of intracerebral hemorrhage: a systematic review. J Neurosurg Sci. 2018 Aug 28. doi: 10.23736/S0390-5616.18.04557-5. [Epub ahead of print] PubMed PMID: 30160081.
3)

Hersh EH, Gologorsky Y, Chartrain AG, Mocco J, Kellner CP. Minimally Invasive Surgery for Intracerebral Hemorrhage. Curr Neurol Neurosci Rep. 2018 May 9;18(6):34. doi: 10.1007/s11910-018-0836-4. Review. PubMed PMID: 29740726.
4)

Mendelow AD. Surgical Craniotomy for Intracerebral Haemorrhage. Front Neurol Neurosci. 2015 Nov;37:148-54. doi: 10.1159/000437119. Epub 2015 Nov 12. PubMed PMID: 26588582.
5)

Zheng J, Li H, Guo R, Lin S, Hu X, Dong W, Ma L, Fang Y, Xiao A, Liu M, You C. Minimally invasive surgery treatment for the patients with spontaneous supratentorial intracerebral hemorrhage (MISTICH): protocol of a multi-center randomized controlled trial. BMC Neurol. 2014 Oct 10;14(1):206. doi: 10.1186/s12883-014-0206-z. PubMed PMID: 25300611; PubMed Central PMCID: PMC4194378.
6)

Hu Y, Cao J, Hou X, Liu G. MIS Score: Prediction Model for Minimally Invasive Surgery. World Neurosurg. 2016 Dec 31. pii: S1878-8750(16)31417-6. doi: 10.1016/j.wneu.2016.12.102. [Epub ahead of print] PubMed PMID: 28049035.
7)

Hwang SC, Yeo DG, Shin DS, Kim BT. Soft membrane sheath for endoscopic surgery of intracerebral hematomas. World Neurosurg. 2016 Mar 9. pii: S1878-8750(16)00405-8. doi: 10.1016/j.wneu.2016.03.001. [Epub ahead of print] PubMed PMID: 26970478.

Minimally Invasive Lumbar Laminectomy

Minimally Invasive Lumbar Laminectomy

see also Lumbar microendoscopic spinal decompression surgery.

Minimally Invasive Lumbar Laminectomy via unilateral approach is one of the minimally invasive methods used for degenerative spinal stenosis.

Bilateral decompression through unilateral approach is an effective method without instability effect, which provides sufficient decompression in the degenerative stenosis and increases patient comfort in the postoperative period 1).

see Laminotomy

see Facetectomy

Microsurgical technique

Development of microsurgical techniques have provided innovations towards minimizing the surgical insult in surgical approaches to canal stenosis 2).

The advantage of a microsurgical approach is the posibility of a wide bilateral decompression of spinal canal or foramen at one or multiple levels, through a minimal paraspinal muscular dissection. As a result, it is possible to preserve important soft tissues and bones, which are vital for the stability of the spinal column, while at the same time being able to remove bilateral pathologies encroaching upon the spinal canal or foramina 3).

Several authors have developed various microdecompression procedures for lumbar canal stenosis, including microhemilaminotomy, interlaminar microdecompression, intersegmental microdecompression, resculpturing microlaminoplasty and segmental microsublaminoplasty 4).

Relevant articles were identified from six electronic databases. Predefined endpoints were extracted and meta-analyzed from the identified studies.

Satisfaction rates were significantly higher in the minimally invasive group (84% vs 75.4%; P = 0.03), while back pain VAS scores were lower (P < 0.00001). Minimally invasive laminectomy operative duration was 11 minutes longer than the open approach (P = 0.001), however this may not have clinical significance. However, there was less blood loss (P < 0.00001) and shorter hospital stay (2.1 days; P < 0.0001). Dural injuries and cerebrospinal fluid leaks were comparable, but reoperation rates were lower in the minimally invasive cohort (1.6% vs 5.8%; P = 0.02) however this was not significant when only randomized evidence was considered.

The pooled evidence suggests ULBD may be associated with less blood loss and shorter stay, with similar complication profiles to the open approach. These findings warrant verification in large prospective registries and randomized trials 5).

Using a decision-analytic model from the Medicare perspective, a cost-effectiveness analysis was performed comparing mild® to ESI or laminectomy surgery. The analysis population included patients with LSS who have moderate to severe symptoms and have failed conservative therapy. Costs included initial procedure, complications, and repeat/revision or alternate procedure after failure. Effects measured as change in quality-adjusted life years (QALY) from preprocedure to 2 years postprocedure. Incremental cost-effectiveness ratios were determined, and sensitivity analysis conducted. The mild® strategy appears to be the most cost-effective ($43,760/QALY), with ESI the next best alternative at an additional $37,758/QALY. Laminectomy surgery was the least cost-effective ($125,985/QALY) 6).

Trumpet laminectomy fenestration

In the Japanese Neurosurgical Society, one of the common procedures for microdecompression of lumbar spinal canal is trumpet laminectomy fenestration.

see Trumpet laminectomy microdecompression.

A 68-yr-old male entailing a 2-level minimally invasive lumbar laminectomy and foraminotomy at L2L3 and L3L4. The patient initially presented with symptoms of treatment-refractory lower extremity numbness and limited ambulation. His imaging demonstrated coronal scoliosis and severe lumbar central and foraminal stenosis at L2-L3 and L3-L4, with enlarged spinous processes, laminae, and facets. The patient consented to the procedure and publication of their image. The operation proceeded with the patient in a prone position with paramedian dissection to the lamina through a minimally invasive tubular retractor. Laminectomies and foraminotomies were performed at each level with high-speed drill and a Kerrison rongeur, with care to identify and protect the relevant spinal nerve roots. Postoperatively, the patient reported significantly reduced numbness and improved ambulation, with a well-healed surgical incision notably smaller than those produced in an open operation 7).


1)

Yaman O, Ozdemir N, Dagli AT, Acar E, Dalbayrak S, Temiz C. A Comparison of Bilateral Decompression via Unilateral Approach and Classic Laminectomy in Patients with Lumbar Spinal Stenosis: A retrospective Clinical Study. Turk Neurosurg. 2015;25(2):239-45. doi: 10.5137/1019-5149.JTN.8710-13.1. PubMed PMID: 26014006.
2)

Caspar W, Papavero L, Sayler MK, Harkey HL. Precise and limited decompression for lumbar spinal stenosis. Acta Neurochir (Wien) 1994;131:130–136.
3)

Guiot BH, Khoo LT, Fessler RG. A minimally invasive technique for decompression of the lumbar spine. Spine (Phila Pa 1976) 2002;27:432–438.
4)

Young JP, Young PH. The textbook of spinal surgery. Bridwell KH, Dewald RLPhiladelphia: Lippincott; 2012. pp. 101-109
5)

Phan K, Mobbs RJ. Minimally Invasive Versus Open Laminectomy for Lumbar Stenosis – A Systematic Review and Meta-Analysis. Spine (Phila Pa 1976). 2015 Oct 17. [Epub ahead of print] PubMed PMID: 26555839.
6)

Udeh BL, Costandi S, Dalton JE, Ghosh R, Yousef H, Mekhail N. The 2-Year Cost-Effectiveness of 3 options to Treat Lumbar Spinal Stenosis Patients. Pain Pract. 2014 Jan 3. doi: 10.1111/papr.12160. [Epub ahead of print] PubMed PMID: 24393198.
7)

Srinivasan ES, Crutcher CL, Wang TY, Grossi PM, Than KD. Two-Level Minimally Invasive Lumbar Laminectomy and Foraminotomy: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown). 2021 May 6:opab134. doi: 10.1093/ons/opab134. Epub ahead of print. PMID: 33956988.
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